Module guide · Operations

Quality Management

TJC/CMS/AHRQ-aligned governance in one hub: track measured quality indicators against targets and national benchmarks, run accreditation audits through corrective action, investigate incidents with root cause analysis, govern policies through a review cycle, and run committee meetings with minutes and action items.

Overview Dashboard Indicators & KPIs Audits Incidents & RCA Policies Committee meetings Good practices

What this module is for

Every screen requires quality/compliance/safety-officer-tier access; most create and workflow actions narrow further from there.

Who uses it

Super admins, admins, directors, quality staff, compliance staff, and safety officers can open every screen. Managing indicators, validating KPI snapshots, scheduling audits, and managing policies excludes safety officers; incidents and RCA workflow include them; committee meeting management is quality/compliance/director/admin only.

Where to find it

Open Quality Management from the sidebar. A dashboard, plus Indicators, KPI, Audits, Incidents, RCA, Policies, and Committee Meetings.

1
Define what you measure
The Indicator Registry defines each metric's meaning, unit, target, and regulatory coding; KPI snapshots record its actual measured values over time.
2
Audit against standards
Schedule an audit, log findings and corrective actions, and track them to verified closure.
3
Investigate incidents
This module's own incident register feeds a Root Cause Analysis workflow with a hard TJC 45-day submission deadline for sentinel events.
4
Govern policies and meetings
Policies move Draft → Active on a review cycle; committees record minutes, quorum, and action items.

A separate module handles hospital-wide incident reporting

This module's Incidents and RCA screens are its own internal register feeding its own root-cause workflow. The hospital-wide sentinel-event/regulatory-reportable/CAPA system lives in the separate Incident Reporting module, they aren't the same records.

Dashboard

Executive overview across compliance scores, audits, incidents, RCA, policies, and committees.

Compliance gauges

Field	What it means
Overall, TJC, CMS, HIPAA Compliance	Green ≥90%, amber ≥75%, red below 75%.

Stat tiles cover Open/Overdue Audits, Corrective Actions, Sentinel Events, Overdue RCA (TJC 45-day), Active Policies overdue for review, and Committee Meetings this month. Panels show Key Indicators with trend arrows, Threshold Breaches, Upcoming Audits, and Incidents by Type. Export Summary downloads a PDF.

Indicators & KPIs

The registry defines each metric; KPI snapshots record its actual measured values.

Indicator Registry — "New Indicator" form

Field	What it means
Metric, Display Name, Domain*	Metric is one of ~50 fixed measures across Utilization, Patient Safety, Mortality, Timeliness, Patient Experience, Clinical Effectiveness, Operational, and Financial Quality.
Target Value, Threshold Alert, Benchmark Value & Source	Threshold Alert is what triggers a breach warning.
CMS/TJC Measure ID, LOINC Code, Publicly reported, Mandatory report
Calculation Formula, Data Source, Inclusion/Exclusion Criteria

KPI Dashboard & "Record Snapshot" form

Field	What it means
Metric, Value, Period, Period Start/End*
Compute vs. Record mode	Compute auto-derives trend direction from the last 3 months; Record saves exactly what's entered, for back-entry.
Department, Data Source, Preliminary value, Notes
Numerator, Denominator, Sample Size	For rate-based metrics.

A per-metric Trend page charts value over time against a department overlay, and lets management Validate preliminary snapshots.

Improving —

Stable —

Declining —

Audits

Accreditation and compliance audits, from scheduling through findings, corrective actions, and closure.

"Schedule Audit" form

Field	What it means
Title, Audit Type, Auditor, Audit Date*	Type: Internal, External, TJC, CMS, HIPAA, OSHA, ISO 9001, CAP-Pathology, and more.
Scope, Standards Reference, Passing Threshold %	Threshold defaults to 80.
This is a follow-up audit, Immediate threat to life identified	Checkboxes.

Lifecycle: Start Audit → Complete Audit (Findings Summary + Score) → Close Audit, or Escalate to Remediation, or Cancel with a reason. Each finding is a Deficiency, Requirement for Improvement, Observation, Compliant, or Not Applicable, with its own priority and resolve action. Each Corrective Action has an owner, due date, and moves Open → Verified (Effectiveness Rating 1–5) → Closed.

Incidents & RCA

This module's own patient-safety incident register, feeding a root cause analysis workflow with a hard TJC deadline.

"Report Incident" form

Field	What it means
Incident Type, Severity, Occurred At, Description*	Severity: Near Miss, Minor, Moderate, Major, Catastrophic, or Sentinel.
NCC MERP Category	Medication-error-specific A–I scale.
Patient/Family Notified, Physician Notified, TJC Sentinel Event, Requires External Report	Checkboxes, updatable later.

On the detail page: Notify Patient/Physician, Flag Sentinel Event (triggers a mandatory RCA), Submit External Report, and Start RCA or Link Existing RCA.

"Initiate RCA" form

Field	What it means
Incident ID, Event Date, Team Leader, Problem Statement*
Methodology	Five Whys, Fishbone, FMEA, or Combined; defaults to Fishbone.
5 Whys, Fishbone categories	Fishbone covers People, Process, Equipment, Environment, Communication, IT, Rules/Policies, Barriers.
Root Causes, Contributing Causes, Action Plan, Lessons Learned

TJC's 45-day rule

A sentinel event's RCA must be submitted to The Joint Commission within 45 calendar days. The system computes a due date and flags any RCA past it as TJC Overdue, both on the record and on the dashboard.

Policies

Hospital policy registry with versioning, approval, and a recurring review cycle.

"New Policy" form

Field	What it means
Title, Category, Owner Name*	Category: Clinical, Administrative, Infection Control, Medication Management, Patient Rights, Environment of Care, HIPAA, HR, Emergency Management.
Version, Review Cycle (months), Effective/Expiration Date	Review Cycle defaults to 36 months.
Purpose, Scope, Policy, Procedure	Full policy text.
Regulatory References, Related Policies, Staff acknowledgement required

Lifecycle: Submit for Review → Approve (Approver ID/Name) → Activate → Mark Reviewed (resets the review clock) → Retire (optionally linking a superseding policy). Overdue and Upcoming Reviews screens (15/30/60/90-day windows) track the review cycle.

Committee meetings

Governance meetings with attendance, quorum, minutes, and action items.

"Schedule Meeting" form

Field	What it means
Committee Type, Title, Meeting Date, Chairperson*	Type: Quality Improvement, Patient Safety, Infection Control, Pharmacy & Therapeutics, Peer Review, Medical Executive, Board.
Attendees (name, role, present), Agenda (ordered items)

A live quorum banner recalculates from the present-attendee checkboxes. Complete Meeting records Final Minutes; Approve Minutes requires an Approver; Reschedule or Cancel are available while still scheduled. Action Items (owner, due date, status) stay editable regardless of meeting status.

Good practices

Set a threshold alert on every indicator you track closely

It's what drives the dashboard's Threshold Breaches panel, without one, a metric can drift without anyone noticing.

Use Compute mode for routine snapshots, Record mode only for back-entry

Compute keeps trend direction accurate automatically; manual Record entries skip that calculation entirely.

Flagging Sentinel Event starts a 45-day clock you can't pause

Only flag it once you're confident, but don't delay past confirmation, TJC Overdue status hits the dashboard the moment the window closes.

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